Surgical management of juxtahepatic venous injuries in blunt hepatic trauma

The purpose of this analysis was to understand better the problems faced in the management of blunt juxtahepatic venous injuries and to try and simplify the controversies regarding the optimal surgical approach to these injuries. Charts of 92 blunt liver trauma patients treated between July 1, 1991 to June 30, 1993 were reviewed. Nineteen patients with blunt juxtahepatic venous injuries were identified. The isolated left hepatic vein injury group (five patients) were all treated using a nonshunting approach with no mortalities. Half of the isolated right hepatic vein injury group (ten patients) received an atriocaval shunt, and the other half did not. These two different approaches each produced one survivor, with a combined mortality rate of 80% (eight of ten patients). One of the combined injuries group (four patients) received a total hepatectomy followed by liver transplantation. Another received a shunt. The other two were treated without shunting, but all of them expired. The overall mortality rate was 63.2% (12 of 19 patients), with nine patients dying intraoperatively or immediately postoperatively from exsanguination. The other three died 10, 25, and 30 days postoperatively because of sepsis. Juxtahepatic venous injury should be suspected after failure of the Pringle maneuver to stop bleeding and the different venous injuries differentiated by palpation of the adjacent hepatic parenchymal injuries. If an isolated left hepatic vein injury is found and the liver parenchymal injury is limited to segments II, III, or IV, then a nonshunting approach will achieve the optimal outcome.